Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XI

The Politics of Hysteria
Joan Acocella, The New Yorker- 4/6/1998

In late 1989, Elizabeth Carlson, a thirty-five-year-old woman who lived with her husband and two children in a Minneapolis suburb, was in the hospital being treated for severe depression. She was referred to a psychiatrist, Diane Humenansky, who came to see her and went on seeing her after she left the hospital. As Carlson recalls, Humenansky soon suggested to her that perhaps her problem was not depression but multiple personality disorder. M.P.D., Humenansky explained, was an elusive illness: many diagnosticians failed to recognize the alternating personalities, or alters, for what they were, with the result that the woman--nine out of ten people with M.P.D. were women--often ended up getting misdiagnosed. But experts now knew that there were certain telltale signs of M.P.D. Did Carlson ever "zone out" while driving, and arrive at her destination without remembering quite how she got there? Why, yes, Carlson said. Well, that was an alter taking over the driving and then vanishing again. Another sign, Humenansky said, was "voices in the head." Did Carlson ever have internal arguments, telling herself, for example, "Turn right--no, turn left"? Yes, Carlson replied, that happened sometimes. Well, that was the alters quarrelling inside her head. Carlson was amazed and embarrassed. All these years, she had done these things, never realizing that they were symptoms of a serious mental disorder.
    Multiple personality, Humenansky explained, was associated with childhood sexual abuse, though the abuse might be forgotten. Carlson should think hard: had anyone ever taken liberties with her? Carlson didn't have to think hard. She distinctly remembered being molested by two men in her family. That didn't mean there weren't other episodes, Humenansky said. Worse ones, maybe.
    To help Carlson remember, Humenansky gave her books to read. One was Ellen Bass and Laura Davis's 1988 "The Courage to Heal," now known as the Bible of the recovered-memory movement. A third of American women were sexually abused as girls, "The Courage to Heal" stated, and if a woman was repeatedly molested she might have not only forgotten it but developed new personalities in which to seal off the terrible knowledge. "The Courage to Heal" gave first-person accounts. In a later edition, one woman wrote:

I remember splitting for the first time when I was about four and my father was trying to force me to sodomize my pet rabbit with a roofing nail. He got very angry when I refused, and finally, in a rage, he threw me down on the basement floor and raped me. When I came back to myself after the experience, here were three parts of me.... Benjamin-ageless, spiritual and protective; Bunny-little and worried; and Scarlet, the only female and the one who dealt with the sexual abuse.

    Humenansky also gave Carlson books about M.P.D. cases. One was the 1957 classic "The Three Faces of Eve," by Corbett Thigpen and Hervey Cleckley, the story of the shy housewife "Eve White" who on the odd weekend would metamorphose into "Eve Black," a vivacious party girl, leaving Eve White with unexplained hangovers and a reputation in local bars. As a result of this book and the 1957 movie based on it, featuring an Academy Award-winning performance by Joanne Woodward, Eve became, for awhile, the prototype of the multiple personality. In later cases, as in Eve's, there was often the naughty/nice split-- "librarian by day and streetwalker by night," to quote the M.P.D. expert Frank Putnam.
    Eve, however, was merely the John the Baptist of multiple personality; the Christ was "Sybil Dorsett," a Columbia University graduate student who in 1954, at the age of thirty-one, turned up in the office of the psychiatrist Cornelia Wilbur and stayed for eleven years. In 1973, this case became the subject of a best-selling book, "Sybil," by a journalist named Flora Rheta Schreiber. Three years later, the book was turned into a TV movie, with Sally Field as Sybil and Joanne Woodward, passing the torch, as Dr. Wilbur. Sybil became the most famous psychiatric patient in history, and the new model of multiple-personality disorder, in a form different from Eve's. For one thing, M.P.D. now had a clear cause: childhood sexual abuse. Eve had suffered traumas as a child, but she was never sexually assaulted. Sybil was repeatedly, by her mother. Furthermore, the mother's actions were sadistic, perverse, extravagant. According to the book, she probed the child's vagina with a knife and a buttonhook. She hung her upside down and, using an enema bag, filled her bladder with ice-cold water, then tied her to the family piano and forbade her to urinate while she, the mother, played Chopin. A second difference between Eve and Sybil was in the number of alters. As described by her therapists, Eve had had only three faces. ("Eve White" and "Eve Black" were later joined by "Jane.") Sybil had sixteen personalities. One could play the piano; another could install Sheetrock; two had English accents; two were boys. Sybil wasn't so much a person as a club.
    Prior to Sybil, M.P.D. had been one of the rarest of mental disorders. In a 1944 article, two researchers, W. S. Taylor and Mabel Martin, reported that a search of the medical literature had yielded only seventy-six cases that met their definition. But after Sybil M.P.D. exploded. One expert estimated that between 1985 and 1995 there were almost forty thousand new cases. Like Sybil, the modal M.P.D. patient was a white North American female around age thirty. Like Sybil, she said she had suffered child abuse, usually sexual. But Sybil's descendants outstripped her. Patients were soon producing a hundred, four hundred, a thousand alters. And, whereas Sybil had confined herself to human alters, later M.P.D.s branched out. The Georgia-based psychiatrist George Ganaway, one of the first authorities to caution against the fascination with M.PD., reported that he had been presented with "sages, lobsters, chickens, tigers, a gorilla, a unicorn, and 'God.'" In recollections of abuse, too, Sybil was rapidly outdone. Multiples were now reporting rape and sodomy--indeed, "satanic ritual abuse."
    Both Eve and Sybil had been suicidal, but the multiple personalities of the eighties and nineties were more ingeniously self-destructive. In one popular M.P.D. biography, "Suffer the Child," the subject pours drain cleaner on her genitals. Other multiples have shown journalists self-inflicted cuts and third-degree burns. Self-mutilation was accepted by many M.P.D. writers as a regular feature of the disorder, a "coping mechanism." Starting in 1990, self-mutilating patients had a newsletter, The Cutting Edge. In a recent issue, "Carla" writes that she doesn't really want to stop cutting herself, and that her new therapist has left the decision up to her, so she's cutting again, "yet it's been a time of tremendous growth and potential."
    Until about 1975, there had been no M.P.D. specialty. Multiple personality disorder had no separate listing in the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders," or D.S.M., the guidebook to diagnosis. But in 1980, after vigorous lobbying by interested therapists, the new edition of D.S.M. gave M.P.D. a primary-level listing among the dissociative disorders--conditions in which some part of mental functioning splits off from consciousness. In 1984, the new M.P.D. enthusiasts founded an organization of their own, the International Society for the Study of Multiple Personality and Dissociation (I.S.S.M.R. & D.), and began holding annual conferences, co-sponsored by Rush Presbyterian St. Luke's Medical Center, in Chicago. That hospital subsequently set up the country's first dissociative-disorders unit, under the M.P.D. expert Bennett Braun. Other units followed. Between 1970 and 1990, the average annual output of publications on M.P.D. increased six thousand per cent.
    Among those publications were two 1989 textbooks: "Diagnosis and Treatment of Multiple Personality Disorder," by Frank Putnam, and "Multiple Personality Disorder," by Colin Ross. Both offered treatment plans focussing on presumed childhood abuse. Using hypnosis, the therapist was instructed to flush out the alters and get them to divulge their secrets, a process that often involved protracted reenactments called "abreactions." In a typical abreaction, as Colin Ross described it, the patient might "cry out, plead with the father to stop, clutch her pubic area, try to push the father off, attempt to spit out semen, or curl up in the corner." These were violent scenes. David Calof, an M.P.D. therapist who has worked in nursing homes, reports that one of his patients had a stroke during an abreaction.
    Confronted with this information, many therapists began viewing their patients in a new light. That is apparently what happened with Diane Humenansky. She attended lectures and read books on M.P.D. She spoke to Cornelia Wilbur. Soon she had a number of newly diagnosed multiples under her care. Humenansky has declined to be interviewed for this article; therefore my account of her treatment of Carlson is largely Carlson's account. It is hard to know what Humenansky was thinking. Carlson says Humenansky told her she had been through three divorces, had lost custody of her children to her third husband, and was herself taking antidepressants. In 1989, when she began treating Carlson, Humenansky was still a fully accredited physician--a graduate of Wayne State Medical School, though, according to Carlson, she claimed it was Harvard--with admitting privileges at several Twin Cities hospitals.
    Carlson says Humenansky gave her not just books but videotapes: the movie versions of "Sybil" and "The Three Faces of Eve," pornographic films, war footage of people being decapitated. She said that if Carlson felt any physical discomfort while watching the videos, that was a "body memory": it meant that such things had happened to her, too. Carlson also says that Humenansky had her do visualization exercises, "trying on" scenes of molestation by various people. Using this technique, Carlson soon recovered memories of being molested by as many as fifty relatives, including both parents, both sets of grandparents, aunts, uncles, and great-grandparents.
According to Carlson, Humenansky also used a technique called guided imagery, in which the patient is talked through an imaginary scene in order to awaken buried memories. In one scenario, Humenansky told Carlson to picture herself going downstairs. Look for an altar, Humenansky said. Carlson saw a stone slab. Look around for candles and daggers, Humenansky said. Carlson saw them. Now look for the baby, Humenansky said. Carlson does not remember at what point her own imagination, primed by the books and videos, took over, but soon she saw a pregnant woman. Then the baby was born, and the afterbirth was lying on the altar, and people in hooded robes were eating it, and so was she. (That was the first cannibalism scene Carlson recovered with Humenansky. Today, nine years later, she still has nightmares.) The therapy sessions often ended with Carlson's weeping uncontrollably. Carlson says Humenansky would give her tranquilizers and tell her to chew them so that they would take effect faster.
    It wasn't long before Carlson, under Humenansky's guidance, began identifying her different personalities. One of them was Little Miss Fluff, a nickname that she had been given as a child because she liked frilly dresses and crinolines. In the Eve Black slot, Carlson produced a hussy named Nikita. Sybil had had two male alters; so, quite soon, did Carlson. She also located two nuns, Sister Mary Margaret and Sister Mary Theresa (the latter wanted to join the Peace Corps) and a scared, depressed Old Lady.
    When Carlson's mood changed, Humenansky told her she had "switched," or changed alters. If she showed up for her session in a short skirt, that meant that Nikita was "out." If she was depressed, that was the Old Lady taking over. Interestingly, though--and this seems to be the case with many multiples who have not written memoirs--Carlson never quite got the hang of multiplicity. To this day, she doesn't know how many personalities she had. "After twenty-five, I lost count," she says. Humenansky had Carlson write down their names, ages, and key memories on index cards for reference, but, Carlson says, "I still couldn't keep the darn things straight." Once, she lost the card file, and they had to do the whole business all over again. Sometimes, she would walk into Humenansky's office and say that she didn't want to explore alters that day--she just needed to talk. Carlson recalls, "Dr. Humenansky said, `Well, who am I talking to?' And I would say, `This is just me, Elizabeth.' She said, `No, I want to know which alter I'm talking to.' `It's not an alter,' I said. `It's just me.' Finally she got out an index card and wrote down 'Just Me.'"
    Meanwhile, Carlson's mental condition was worsening. The main events of her week were her two appointments with Humenansky--an individual session and a group session with other M.P.D. patients. For a year, Carlson was so depressed that she rarely left her bedroom. Heavily drugged, she sometimes slept eighteen or twenty hours a day. She had terrible nightmares and woke up screaming and vomiting. "I stank, the room stank," she remembers. "Every few days or so, my husband or my daughter would take me and shove me into the shower and hose me down." Then she would go back to bed. Carlson's daughter, Lisha, who was in her teens, took over the household and the care of her younger brother. Eventually, she had to drop out of school. Carlson's marriage, which had already been troubled when she first began seeing Humenansky, deteriorated day by day. Carlson says Humenansky suggested that perhaps her husband was trying to kill her. Carlson threw him out of the house repeatedly. Meanwhile, she had cut off all contact with the rest of her family, because, as she now understood, they were still members of the cult that had abused her as a child, and if they found out what she was revealing in therapy they would murder her.
    "I just got crazier and crazier," Carlson recalls. She banged her head on walls and tore out her hair in chunks. "I was ready to kill myself. I thought it was better for me, and better for my children." When, in rare moments of protest, she asked Humenansky why the therapy wasn't helping, the doctor repeated to her a basic principle of M.P.D. treatment: "The patient has to get worse in order to get better."
    How could Carlson have believed what Humenansky was telling her? M.P.D. patients are often given strong medications--particularly benzodiazepines, such as Valium, Halcion, and Xanax. (In a 1995 court case, Colin Ross acknowledged that he had had one patient on fifty-one milligrams of Halcion a day, which is a hundred times the prescribed maximum for that drug.) During her time with Humenansky, Carlson took Xanax, Valium, and Ativan for anxiety; Pamelor, Desyrel, and Prozac for depression; and Restoril for insomnia. In the words of one former patient, "If you take enough drugs, you can remember about anything."

The above text covers the first three pages of this eleven page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.
   .

How I Perceive and Manage My Illness
Esso Leete (1989), Schizophrenia Bulletin, 15, pp.197-200

    More than by any other one thing, my life has been changed by schizophrenia. For the past 20 years I have lived with it and in spite of it--struggling to come to terms with it without giving in to it. Although I have fought a daily battle, it is only now that I have some sense of confidence that I will survive my ordeal. Taking responsibility for my life and developing coping mechanisms has been crucial to my recovery. I would like to share some of these with the reader now.
    To maintain my mental health, I found I had to change my priorities and take better care of myself. I modified my attitudes, becoming more accepting and nonjudgmental of others. In addition, I altered my behavior and response to symptoms. I have also had to plan for the use of my time. When one has a chaotic inner existence, the structure of a predictable daily schedule makes life easier. Now, obviously structured activity can be anything, but for me it is work--a paying job, the ultimate goal. It gives me something to look forward to every day and a skill to learn and to improve. It is my motivation for getting up each morning. In addition, my hours are passed therapeutically as well as productively. As I work, I become increasingly self-confident, and my self-image is bolstered. I feel important and grownup, which replaces my usual sense of vulnerability, weakness, and incompetence. Being a member of the work force decreases stigma and contributes to acceptance by my community, which in turn makes my life easier.
    Research continues to show that one of the differences between the brain of a "normal" person and one who has schizophrenia is a major difficulty filtering or screening out background noises. I am hyper-alert, acutely aware of every sound or movement in my environment. I am often confused by repetitive noises or multiple stimuli and become nervous, impatient, and irritable. To deal with this, I make a deliberate effort to reduce distractions as much as possible.
    I often have difficulty interacting with others socially and tend to withdraw. I have found I feel more comfortable, however, if I socialize with others who have similar interests or experiences to my own. To counteract my problem with poor eye contact, I force myself to look up from time to time, even if I have to look a little past the person with whom I am speaking. If I do become overwhelmed in a social situation, I may temporarily withdraw by going into another room (even the restroom) to be alone for a while.
    I attempt to keep in touch with my feelings and to attend immediately to difficulties, including symptoms like paranoia. For example, instead of constantly worrying about the police surprising me, I always choose a seat where I can face the door, preferably with my back to a wall instead of to other people. In general, instead of working myself up emotionally over some threatening possibility, I will check out reality by asking the people I am with questions like who they are calling, where they are going, or whatever. It clears the air immediately, and usually I am satisfied with their answer and can go on about my business. In other words, I cope by recognizing and confronting my paranoid fears immediately and then moving on with my life, freeing my mind for other things. Also, I have learned to suppress paranoid responses, and I make an effort not to talk to myself or to my voices when others are nearby. It can be done through self-discipline and practice.
    In addition, I suffer from feelings of isolation, alienation, and loneliness. This is difficult to deal with because on the one hand I need to be with people, but on the other hand I am frightened of it. I have come to realize my own diminished capacity for really close friendships, but also my need for many acquaintances. An ongoing and reliable support system has been extremely important. I have gained much practical information, insight, and support from my peer-run support group, a very comfortable means of coming to accept and deal with mental illness. Also, it has been invaluable to have someone I trust (often my husband) with whom I can "test reality." I let him know my perceptions and he gives me feedback. I am then able to consider the possibility that my perceptions may not be accurate, and I modify my response accordingly if I wish. In this way I can usually acknowledge more conventional ways of thinking, instead of automatically incorporating outside information into my delusional system.
    A common complaint from persons with a mental illness is that of impaired concentration and memory. This can make holding a job or even completing a thought very difficult. To overcome the effects of a poor memory, I make lists and write down all information of importance. Through years of effort I have managed to develop an incredible amount of concentration, although I am only able to sustain this for relatively brief periods of time.
    Sometimes, I still find it difficult to keep my thoughts together. 1 therefore request that communication be simple, clear, and unambiguous. It helps me if the information is specific, as vague or diffuse responses only confuse me. When speaking to someone, I may need more time to think and understand before responding, and I take this time. Likewise, I have learned when working on a task to be careful, perhaps taking more time than others, and to concentrate fiercely on what I am doing. And I must be persistent.
    Many times when becoming acutely ill, I am frightened of everything, feeling small and vulnerable. When I am in distress, I do whatever makes me feel better. This may be pacing, curling up into a ball, or rocking back and forth. I have found that most of these behaviors can be accomplished without appearing too strange, believe it or not. For example, I can pace by taking a walk, I can curl up when I sleep, and I can rock in a rocking chair or hammock or even by going to an amusement park. I am often able to relax by physically exercising, reading, or watching a movie. In general, then, I think I am discovering how to appear less bizarre.
    I find it crucial to schedule time between events rigidly. For example, I will not agree to give two talks on the same day. I find I must also give myself as much time as I can in which to make decisions; I have an enormous amount of ambivalence, and pressure to come to a decision quickly can immobilize me (It is not a pretty picture.) Too much free time is also detrimental. Therefore, I find it useful to structure my leisure time and to limit it. Perhaps some day I will be able to handle it in greater increments, but for now I find it best to keep very busy, with minimal amounts of leisure time.
    Perhaps the coping strategy I use the most is compulsive organizing. I think a controlled environment is probably so important to me because my brain is not always manageable. Making lists organizes my thoughts. It also increases self-esteem, because when I have accomplished something and crossed it off my list, it is a very concrete indication to me that I am capable of setting a goal, working toward it, and actually accomplishing it. These "small" successes build my confidence to go out and try other things. As a part of this process, I break down tasks into small steps, taking them one at a time. Perhaps organizing and giving speeches about my illness is another coping skill--and the audience response is a type of reality-testing.
    In general, then, I believe I do have an irritable brain. I am supersensitive to any stimulus. My behavior is sometimes erratic, and I am easily frustrated and extremely impulsive. I regret that I still have times of uncontrollable angry outbursts. I cope with these and other symptoms by taking low doses of medication. Before I came to realize the role medications could play in my illness, I was caught in a vicious circle. When I was off the medication, I couldn't remember how much better I had felt on it, and when I was taking the medication, I felt so good that I was convinced I did not need it. Fortunately, through many years of trial and error, I have learned what medication works best for me and when to take it to minimize side effects based on my daily schedule. Increasing my medication periodically is one means I often use for stabilization during a particularly stressful period.
    I want to emphasize that stress does play a major role in my illness. There are enormous pressures that come with any new experience or new environment, and any change, positive or negative, is extremely difficult. Whatever I can do to decrease or avoid high-stress situations or environments is helpful in controlling my symptoms. In general terms, all of my coping strategies largely consist of four steps. (1) recognizing when I am feeling stressed, which is harder than it may sound; (2) identifying the stressor, (3) remembering from past experience what action helped in the same situation or a similar one, and (4) taking that action as quickly as possible. After I have identified a potential source of stress, I prepare mentally for the situation by anticipating problems. Knowing what to expect in a new situation considerably lowers my anxiety about it. In addition, I try to recognize my own particular limitations and plan in advance, setting reasonable goals.
    Please understand that these are the kinds of obstacles that confront individuals with a psychiatric disorder every day. Yet we are perceived as weak. On the contrary, I believe we are among the most courageous. We struggle constantly with our raging fears and the brutality of our thoughts, and then we are subjected as well to the misunderstanding, distrust, and ongoing stigma we experience from the community. Believe me, there is nothing more devastating, discrediting, and disabling to an individual recovering from mental illness than stigma.
    Life is hard with a diagnosis of schizophrenia. I can talk, but I may not be heard. I can make suggestions, but they may not be taken seriously. I can report my thoughts, but they may be seen as delusions. I can recite experiences, but they may be interpreted as fantasies. To be a patient or even ex-client is to be discounted. Your label is a reality that never leaves you; it gradually shapes an identity that is hard to shed. We must transform public attitudes and current stereotypes. Until we eliminate stigma, we will have prejudice, which will inevitably be expressed as discrimination against persons with mental illness.
    We rarely read about people who have successfully dealt with their emotional problems and are making it, and they will not usually identify themselves to us because they are all too aware of the general attitude. The current image the public has of the mentally ill must be changed, not to mention that of the individual himself. We have grown up in the same society and have the same feelings about mental illness, but we must also live with the label.
    Ultimately, we must conquer stigma from within. As a first step--and a crucial one--it is imperative for us as clients to look within ourselves for our strengths. These strengths are the tools for rebuilding our self-image and thus our self-esteem. I found that I first had to convince myself of my worthiness, then worry about others. Each time I am successful at a task it serves to reinforce my own capabilities and boost my confidence. Just this way, persons with mental illness can and must change the views and expectations of others.
    Obviously, education about mental illness is critical for all parties involved, especially for the patient. I have made an extensive study of my disorder and have found education invaluable in understanding my illness, coming to terms with it, and dealing with it. We must conscientiously and continually study our illnesses and learn for ourselves what we can do to cope with the individual disabilities we experience.
    Many of us have learned to monitor symptoms to determine the status of our illness, using our coping mechanisms to prevent psychotic relapse or to seek treatment earlier, thereby reducing the number of acute episodes and hospitalizations. My own personal warning signs of decompensation include fatigue or decreased sleep; difficulty with concentration and memory; increased paranoia, delusions, and hallucinations; tenseness and irritability; agitation; and being more easily overwhelmed by my surroundings. Coping mechanisms may include withdrawing and being alone for awhile; obtaining support from a friend; socializing or otherwise distracting myself from stressors; organizing my thoughts through lists; problem-solving around specific issues; or temporarily increasing my medication. Yet too many times our efforts to cope go unnoticed or are seen as symptoms themselves. If others understood us better, perhaps they would be more tolerant. We did not choose to be ill, but we all choose to deal with it and learn to live with it. By learning to modulate stress, we will more effectively manage our illness, thus endowing ourselves with an ongoing sense of mastery and control. I find my vulnerability to stress, anxiety, and accompanying symptoms decreases the more I am in control of my own life. Unfortunately, our progress continues to be measured by professionals with concepts like "consent" and "cooperate" and "comply" instead of "choose," insinuating that we are incapable of taking an active role as partners in our own recovery.
    I see my schizophrenia as a mental disorder with a genetic predisposition, predictably expressing itself in times of extreme stress, but often exacerbated by rather ordinary fluctuations in my environment. Mental illness is a handicap with biological, psychological, and social ramifications, making it a formidable obstacle to be overcome, I understand that life may be more difficult for me than for others and that I must preside over it more attentively for this reason. As with other chronic illnesses, it has demanded that I work harder than most. I know to expect good and bad times and to make the most of the good. I take my life very seriously and do as much with it as I can when I am feeling well, because I know that I will have difficult times again and will likely lose some of my gains.
    Although there is no magic answer to the tragedy of mental illness, I contend that we need not be at its mercy. Appropriate treatment can help us understand our disease and we can learn to function in spite of it. We can overcome our illness and the myths surrounding it. We can successfully compensate for our disabilities. We can overcome the stigma, prejudice, discrimination, and rejection we have experienced and reclaim our personal validity, our dignity as individuals, and our autonomy. To do this, we must change the image of who we are and who we can become, first for ourselves and then for the public. If we do acknowledge and seriously study our illnesses, if we build on our assets; if we work to minimize our vulnerabilities by developing coping skills; if we confront our illnesses with courage and struggle with our symptoms persistently--we will successfully manage our lives and bestow our talents on society, the society that has traditionally abandoned us.

The Author
At the time of the writing of this article, Esso Leete was the director and founder of the Denver Social Support Group and Program Director of Consumer Centered Services of Colorado. As a primary mental health consumer, she has been on many local committees and boards, as well as being the Vice President of the Client Council of the National Alliance for the Mentally Ill. She has been designated as a national Switzer Scholar and has received an award for the most outstanding consumer advocate in Colorado for the last 25 years.